Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Primary care visit to 15% coinsurance 40% coinsurance treat an injury or illness None If you visit a health Specialist visit 15% coinsurance 40% coinsurance care provider's office Coinsurance and deductible do not apply for childhood or clinic Preventive No charge, deductible does 40% coinsurance, immunizations from out-of-network providers. You may care/screening/ not apply deductible does not apply have to pay for services that aren't preventive. Ask immunization your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 15% coinsurance 40% coinsurance Certain tests aren’t covered, and other tests require If you have a test blood work) preauthorization. Please refer to your plan document. Imaging (CT/PET scans, 15% coinsurance 40% coinsurance *See section Radiology. MRIs) 15% coinsurance for all 15% coinsurance for all Deductible does not apply to covered insulin and Value Tier (Specific high other prescription drugs other prescription drugs certain drugs indicated on the UMP Preferred Drug value prescription drugs List. used to treat certain Covered insulins: 5% Covered insulins: 5% Preauthorization may be required. Please refer to your If you need drugs to chronic conditions) coinsurance up to $10 coinsurance plan document. *See section Your prescription drug treat your illness or maximum benefit. condition 15% coinsurance for all 15% coinsurance for all Up to a 90-day supply / retail prescription (your cost More information about Tier 1 (Low-cost generic other prescription drugs other prescription drugs share is per 30-day supply) prescription drug prescription drugs) Covered insulins: 10% 90-day supply / mail-order prescription coverage is available at coinsurance up to $25 Covered insulins: 10% Postal Prescription Services (PPS) and Costco Mail ump.regence.com/pebb/ maximum coinsurance Order Pharmacy are the plan's only network mail-order benefits/prescriptions 15% coinsurance for all 15% coinsurance for all pharmacies. Tier 2 (Preferred brand other prescription drugs other prescription drugs Specialty drugs must be filled from the specialty drugs and high-cost pharmacy, Ardon Health, except when a drug can only generic drugs) Covered insulins: 30% Covered insulins: 30% be dispensed by a certain pharmacy. coinsurance up to $35 coinsurance Covers up to a 30-day supply for most specialty maximum prescription drugs. *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 2 of 6